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Colles’ fracture reduction techniquesROSALIND OAKES1/12/16
Epidemiology Common
A 50 year old white woman in N Europe and USA has a 15 % lifetime risk of distal radius fracture
2% for men in the same group
Osteoporosis and increased falls in older women
Admission rate is about 20%
Options Aim: To allow the patient to tolerate a painful procedure
Haematoma Blocks
Intravenous Regional Anaesthesia (IVRA) Biers Block
Procedural Sedational
Regional blocks: peripheral nerve blocks (radial median ulnar) & Brachial plexus
GA in theatre
What are the pros and cons of IV regional anaesthesia (Biers block)? 4 marks (2 each)
What are the pros and cons of IV regional anaesthesia (Biers block)? 4 marks (2 each)Pros Cons
Effective May fail
Often well tolerated Risk of local anaesthetic toxicity
No risk of sedation Poor tolerance of pressure cuff
Could use for foot and ankle surgery Staff heavy
Monitored area required
Haematoma Block Prepare skin with Antiseptic solution
5-15mls 1% Lignocaine into fracture cavity and around the adjacent periosteum
Confirm site by aspirating blood
Do not use for open fractures
Roberts & Hedges (2014) p 519
Haematoma BlockPros Cons
Simple, 1 doctor, does not require cardiac monitoring or IV access
Not suitable for fractures with marked displacement
Lower LA dose than Bier’s Less effective than Bier’s in terms of analgesia and usually needs supplemental analgesia E.g. Entonox
Procedural Sedation
Procedural SedationPros Cons
Effective Aspiration‘An unfasted GA with no airway in place…’SE from sedation: hypoxia, hypotension, bradycardiaHigher risk in some patients: OSA, difficult airway
Resource heavy: Resus Bay, monitoring, personnel, time to recoverProceduralist needs anaesthetic experience
Theatre GAPros Cons
Anaesthetic: Less risks than procedural sedation due to airway protection
Logistically unlikely to be able to achieve in a timely manner
Fractures that need an operation anyway.. Preventing double procedure and timePotentially most pleasant option for patient
Anaesthesia for treating distal radial fracture in adults Cochrane (2002)
Attempted to compare all the above methods for outcome in terms of failed/inadequate anaesthesia, anatomical restoration, resource use
1a. Intravenous regional anaesthesia (IVRA) versus haematoma block (5 studies)
IVRA patients experienced significantly less pain during fracture manipulation
Fewer remanipulations
statistically better anatomical post-reduction measurements
No difference between the two groups in the overall time in the accident and emergency department
Regional Blocks Many options for forearm blocks
Peripheral nerve blocks - radial, median ulnar at elbow or supraclavicular, infraclavicular, axillary approach which all target the brachial plexus at different points
Most evidence for regional blocks comes from anaesthesia literature
Different level of training, different patient group
Peripheral NB in non-operative settingsTran et al (2014)
RCTs n=14
Kriwanek et al (2006) Children with forearm fractures AXB v deep sedation (Midaz/ketamine) but transarterial approach not US guided
Blaivas et al (2011) compared interscalene brachial plexus blocks versus procedural sedation for shoulder reduction are found shorter length of stay but similar post reduction pain
Other blocks from this paper relate to femoral nerve blocks in ED or on a ward
GA v US guided brachial plexus block O’Donnell et al (2009)
US guided axillary block v GA evaluating anesthetic and perioperative analgesic outcomes.
Patients were randomized
OOP approach, equal parts 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine with 7.5 mg/mL clonidine was injected after identifying the median, ulnar, radial, and musculocutaneous nerves.
General anesthesia was induction with fentanyl and propofol, maintenance with sevoflurane
All blocks were successful
The block group had lower visual analog scale pain scores in the recovery room in 2 and 6 hours and were discharged earlier
Applications ED
Regional Anaesthesia for Trauma Fleming et al (2013) [a review]
Distal radius fractures undergoing closed reductions in the emergency department are amenable to supracondylar radial nerve block to minimize sedation requirements.
Acute compartment syndrome. A difficult diagnosis and RA could eliminate pain as the presenting symptom. Discuss with Orthopaedics in high risk patients prior to blocking
Trauma induced coagulopathy – ROTEM, neuroaxial blocks
‘Double crush injury’ patients with pre- existing nerve lesions are more susceptible to further injury when exposed to a secondary insult
Unrelieved acute pain is a risk factor for chronic pain 1-4% non operatively managed Colles’ CRPS
Review of evidence of efficacy for PNBKessler (2015)
Nerve Damage
Neuropathy post Axillary NB was 1.48:100 (95% CI: 0.52-4.11:100) with no cases of permanent nerve damage Brull (2007)
For comparison femoral NB post op neuropathy is 0.34:100 (95% CI: 0.04-2.81:100)
However, on postoperative days 1, 7, and 14 there were no differences in pain, opioid consumption, adverse effects, Pain-Disability Index, or patient satisfaction.51
Training
High success rates of 93 – 98 in different retrospective studies with more than 6500 patients can only be achieved after intensive training.
Regional BlocksPros Cons
Small volume of LA compared to IVRA (less risk of toxicity)
Nerve damage & ‘Double crush syndrome’
Less resource used – single operator, no need for a resus bay, no recovery time
Probably the most difficult to learn, high training time required
Patient alert ‘Patchy’ or ineffective blocks leading to supplementary analgesia
Potentially reduces risk of chronic pain Concern about ability to diagnose Compartment Syndrome
Does not expose patient to risk of GA Not well studied in the ED setting
SCGH experience Fracture LA Site Outcome Further
analgesia65 F Radial # 1%
lignocaineRadial below elbow
Analgesia with some motor block in hand
Converted to sedation
68F Radial and Ulnar #
1% Lignocaine
Ulnar, radial Motor block No
85F Radial and Ulnar #
1% lignocaine, 0.2% Ropivicaine
Ulnar, Radial and Median at elbow
Analgesia Converted to sedation
72F Radial # 1% lignocaine,Ropiviciane
Axillary approach
Motor block No
Patient leaflet post block
http://scghed.com/wp-content/uploads/2014/05/Colles-Austin.pdf
References Fleming, I. and Egeler, C., 2013. Regional anaesthesia for trauma: an update. Continuing Education in Anaesthesia, Critical Care & Pain, p.mkt048.
Imasogie, N., Ganapathy, S., Singh, S., Armstrong, K. and Armstrong, P., 2010. A prospective, randomized, double-blind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections. Anesthesia & Analgesia, 110(4), pp.1222-1226.
O’Donnell, B.D., Ryan, H., O’Sullivan, O. and Iohom, G., 2009. Ultrasound-guided axillary brachial plexus block with 20 milliliters local anesthetic mixture versus general anesthesia for upper limb trauma surgery: an observer-blinded, prospective, randomized, controlled trial. Anesthesia & Analgesia, 109(1), pp.279-283.
Mannion, S., 2013. Regional anaesthesia for upper limb trauma: a review. Rom J Anaest Intens Care, 20(1), pp.49-59.
Tran, D.Q., Bernucci, F., Iyaprasertkul, W. and Finlayson, R.J., 2014. Peripheral Nerve Blocks in Non-Operative Settings: A Review of the Evidence and Technical Commentary. Journal of Anesthesia & Clinical Research, 2014.